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Medical Journal Review

October 2020

WAO Reviews – Editors' Choice

The Editors’ Choice comes to you from Juan Carlos Ivancevich, MD, and John J. Oppenheimer, MD, FACAAI, FAAAAI. They select articles for their importance to clinicians who care for patients with asthma and allergic/immunologic diseases, and whenever possible, for their accessibility to everyone.

Risk of COVID-19-related death among patients with chronic obstructive pulmonary disease or asthma prescribed inhaled corticosteroids: an observational cohort study using the OpenSAFELY platform
Schultze A, Walker AJ, MacKenna B, Morton CE, Bhaskaran K et al
The Lancet Respiratory Medicine 2020; Published online ahead of print (24 September)
https://doi.org/10.1016/S2213-2600(20)30415-X

Early reports of patients admitted to hospital during the COVID-19 pandemic showed a lower prevalence of asthma and chronic obstructive pulmonary disease (COPD) than would be expected for an acute respiratory disease like COVID-19. This led to speculation that inhaled corticosteroids (ICSs) might protect against infection with severe acute respiratory syndrome coronavirus 2 or prevent the development of serious sequelae. To determine if this was true, Schultze and colleagues assessed the association between ICS and COVID-19-related death among people with COPD or asthma using linked electronic health records (HER).

They identified 148557 people with COPD and 818490 people with asthma who were given relevant respiratory medications in the 4 months before the index date. People with COPD who were prescribed ICSs were at increased risk of COVID-19-related death compared with those prescribed LABA–LAMA combinations (adjusted HR 1·39 [95% CI 1·10–1·76]). In the case of asthma, compared with those prescribed SABAs only, people who were prescribed high-dose ICS were at an increased risk of death (1·55 [1·10–2·18]), whereas those given a low or medium dose were not (1·14 [0·85–1·54]). Sensitivity analyses demonstrated that the apparent harmful association they observed could be explained by  relatively small health differences between people prescribed ICS and those not prescribed ICS that were not recorded in the database (e value lower 95% CI 1·43). Overall, their results do not support a major role for regular ICS use in protecting against COVID-19-related death among people with asthma or COPD. The authors note that the increased risks of COVID-19-related death could be explained by unmeasured confounding due to disease severity.

Face masks, respiratory patients and COVID-19
Soriano JB, Anzueto A, Bosnic Anticevich S, Kaplan A, Miravitlles M et al
European Respiratory Journal 2020; Published online ahead of print
https://doi.org/10.1183/13993003.03325-2020

At this time, professional associations have not provided clear recommendations on exemptions regarding facemasks. The Respiratory Effectiveness Group notes that they do not see asthma, chronic obstructive pulmonary disease (COPD), and other respiratory diseases as a reason not to wear a face mask, unless the person is in active acute respiratory distress, in which case going out in public is not advised. Therefore, the group proposed the cautionary step to not exempt respiratory patients on the compulsory use of face masks. Furthermore, the group noted that our duty remains to encourage patients to follow strictly the measures aiming at protecting them from getting or transmitting the disease. Adaptations of their activities (less time spent in public spaces) may be required to decrease the time during which they need to wear a face mask, and whenever possible other protective measures could be undertaken (social distancing). COVID-19 is a new, devastating, but potentially preventable disease, and a key priority is to identify the combination of measures that minimizes societal and economic disruption while adequately controlling infection.

Disease control in patients with asthma and respiratory symptoms (wheezing, cough) during sleep
Doenges J, Kuckuck E, Cassel W, Hildebrandt O, Weissflog A et al
Asthma Research and Practice 2020;6:9
https://doi.org/10.1186/s40733-020-00062-w

The GINA-defined criteria for asthma control include questions regarding daytime symptoms, limitation of activity, nocturnal symptoms, need for reliever treatment and patients’ satisfaction. Patients with nocturnal symptoms such as wheezing and cough often suffer from lower sleep quality and impaired daytime performance. The lack of an appropriate method for standardized and objective monitoring of respiratory symptoms leads to difficulties in asthma management. The aim of this study was to evaluate a new method for automated wheeze and cough detection during sleep and to compare it to the level of asthma control as measured by the Asthma Control Test (ACT). Respiratory symptoms including wheeze and cough were recorded with the LEOSound-Monitor for one night in 55 asthmatics. During sleep, wheezing was found in 8 of the 55 asthma patients (14.5%) and coughing was found in 30 patients (54.5%). The median ACT score in wheezing-patients was 14, while in non-wheezing patients it was 21. Uncontrolled asthma was found in 6 of the 8 wheezing-patients. On the other hand, coughing versus non-coughing patients did not show a significant difference in the ACT-score (20, 22 respectively).

Advances and novel developments in allergic rhinitis
Meng, Y, Wang, C, Zhang, L
Allergy 2020; Published online ahead of print (9 September)
https://doi.org/10.1111/all.14586

Although the mechanisms underlying the pathology and treatment of allergic rhinitis (AR) have been widely studied, many aspects of AR are still unclear and warrant further investigation. In this review, the authors explore recently published papers, which explore novel mechanisms and treatments of AR. These include the role of the environment, important proteins and cells integral in the pathogenesis of AR, as well as the role of immunotherapy and biologics in the treatment.

Primary prevention of asthma: from risk and protective factors to targeted strategies for prevention
von Mutius E and Smits HH
The Lancet 2020;396(10254):854-866
https://doi.org/10.1016/S0140-6736(20)31861-4

In this analysis of the epidemiology literature regarding the sequela of various environmental exposures and their potential action as prevention strategies for asthma, von Mutius and Smits note several interesting findings. Some approaches such as the Finnish program of banning smoking have clearly proven successful. Other studies exploring primary prevention of wheeze in pre-school children have appeared promising, such as the supplementation of vitamin D, fish oil, or both, to pregnant women. Lastly, several recent prevention initiatives have been based on strong asthma-protective environmental microbial exposures associated with traditional rural lifestyles. This has led to preclinical studies with various bacterial lysates, bacterial and dietary metabolites, or helminthic compounds which have yielded encouraging results that await translation into clinical practice. As the authors note, given the immense societal and individual burden of asthma, there is an urgent need to develop further novel strategies to eradicate the disease.

 

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